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SOAP Noting System

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  • 1. Omar Hamad AlKadhi, RCsDP SOAPOmar Hamad AlKadhi 1
  • 2. S O A P Omar Hamad AlKadhi, RCsDPContents Subjective Objective • Contents: • Slide 3-4: Introduction • Slide #8: AssessmentPlan • Slide#5: History • Slide #9: Plan • Slide #6: Subjective • Slide #10-11: Example • Slide #7: Objective Assessment 2
  • 3. S O A P Omar Hamad AlKadhi, RCsDPContents SOAP • Importance of complete and efficient noting. • The SOAP system is designed to organize and simplify noting in hospital and office settings for all healthcare professionals. 3
  • 4. S O A P Omar Hamad AlKadhi, RCsDPContents Subjective Objective • Its a square!Plan • Put all the information inside. Assessment 4
  • 5. S O A P Omar Hamad AlKadhi, RCsDPContents SOAP • Start with a brief history. • (Patient’s age, Nationality, Gender , Occupation, Past medical history, Habits, and Past dental history). 5
  • 6. S Omar Hamad AlKadhi, RCsDPContents Subjective • Subjective, Symptoms, Chief Complaint, History of present illness. 6
  • 7. O Omar Hamad AlKadhi, RCsDPContents Objective • What clinical and radiographic examinations reveal. 7
  • 8. A Omar Hamad AlKadhi, RCsDPContents • Assessment, Problem list, Diagnosis. The list is better be numbered and corresponding numbers in the “Plan” section are made. Assessment 8
  • 9. P Omar Hamad AlKadhi, RCsDPContentsPlan • Plan of the treatment, What is going to be done today, and in the Next Visit. 9
  • 10. S O A P Omar Hamad AlKadhi, RCsDPContents Useful Abbreviations Example• Pt Patient • YO Years Old• Med. Medical• Hx History• NKDA No Known Drug Allergies • Hx:• Cig. Cigarettes• EOE Extra-Oral Examination • Pt is 22 yo Saudi , Student. Med Hx is• IOE Intra-Oral Examination• Tx Treatment not significant. NKDA. Not using any• ē With drugs. Smoker 1/2 pack a day of cig.• Tab. Tablet• PRN As needed Dental Hx includes several restoration,• Q6H Every 6 hours• Male RCT and extraction.• Female • S: • CC: "I have severe pain in my upper left last tooth (T#26), the pain is spontaneous and it started 2 days ago, it is betterSubjective when I take Panadol, and I want to fix all my teeth".ObjectiveAssessmentPlan 10
  • 11. S O A P Omar Hamad AlKadhi, RCsDPContents Useful Abbreviations Example• Pt Patient • YO Years Old• Med. Medical• Hx History • O:• NKDA No Known Drug Allergies • EOE:• Cig. Cigarettes• EOE Extra-Oral Examination • Lymph nodes, TMJ, Skin, Lips, and Face• IOE Intra-Oral Examination all WNL.• Tx Treatment• ē With • IOE:• Tab. Tablet• PRN As needed • T#26 Thermal test revealed lingering• Q6H Every 6 hours pain response (CO2).• Male • T#26 is tender to palpation and• Female percussion. • Moderate plaque accumulation, Generalized gingival inflammation, BOP, Loss of stippling, Slight redness, and Edema (see chart).Subjective • RR of t# 46. Missing t#24. • Slight drifting of t#23, 25 into space ofObjective missing t#24. • Radiographically:Assessment •T#26, widening of the PDL space, and a well defined, corticated radiolucent lesion.Plan 11
  • 12. S O A P Omar Hamad AlKadhi, RCsDPContents Useful Abbreviations Example• Pt Patient • YO Years Old• Med. Medical• Hx History• NKDA No Known Drug Allergies• Cig. Cigarettes• EOE Extra-Oral Examination• IOE Intra-Oral Examination• Tx Treatment• ē With• Tab. Tablet• PRN As needed • A:• Q6H Every 6 hours 1. T#26, Caries, Irreversible pulpitis, and• Male Acute Apical Abscess.• Female 2. Generalized Moderate Plaque-induced gingival disease. 3. RR of t#46. 4. Caries in t#16, 26, 34. 5. Missing t#24.SubjectiveObjectiveAssessmentPlan 12
  • 13. S O A P Omar Hamad AlKadhi, RCsDPContents Useful Abbreviations Example• Pt Patient • YO Years Old• Med. Medical• Hx History• NKDA No Known Drug Allergies• Cig. Cigarettes• EOE Extra-Oral Examination• IOE Intra-Oral Examination• Tx Treatment• ē With• Tab. Tablet• PRN As needed• Q6H Every 6 hours • P:• Male 1. RCT and cusp coverage.• Female 2. Scaling and polishing. 3. Extraction of the RR of t#46. 4. Removal of caries and restoration of t#16, 34. 5. Implant or FPD in the space of missingSubjective t#24.ObjectiveAssessmentPlan 13
  • 14. S O A P Omar Hamad AlKadhi, RCsDPContents Useful Abbreviations Procedure• Pt Patient • YO Years Old • Today:• Med. Medical• Hx History • Explained the tx to the patient.• NKDA No Known Drug Allergies • Infiltration anesthesia was administered, 2 carpules 2% lidocaine ē 1:100k adrenaline in the• Cig. Cigarettes• EOE Extra-Oral Examination area of t#26.• IOE Intra-Oral Examination • R.D. Was applied, single isolation.• Tx Treatment• ē With • Caries was removed using a small diamond round bur.• Tab. Tablet • Access cavity was made.• PRN As needed• Q6H Every 6 hours • Canals were identified (P, DB, MB I, MB II).• Male • Pulp extirpation was done using a barbed broach #15.• Female • WL was determined using the apex locator and confirmed radiographically, (P: 20 mm, DB: 19 mm, MB I: 19 mm, and MB II: 18 mm). • Instrumentation was made ē K-files #15, #20, and #25. • Intra-canal medicament (CaOH) was applied. • 2 cotton pellets were placed.Subjective • The cavity was sealed using metal reinforced glass ionomer cement. • Pt was instructed to:Objective • Improve OH. • Take Ibuprofen 400 mg tab. Q6H PRN x3 days.Assessment • N.V.: • instrumentation and obturation of the canals.Plan 14
  • 15. Omar Hamad AlKadhi, RCsDPContents Thank You 15

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